Provider Demographics
NPI:1497330187
Name:MERRYMAN, KISCA KAY (PSS)
Entity Type:Individual
Prefix:
First Name:KISCA
Middle Name:KAY
Last Name:MERRYMAN
Suffix:
Gender:F
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 OAK ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4019
Mailing Address - Country:US
Mailing Address - Phone:503-585-4949
Mailing Address - Fax:
Practice Address - Street 1:1118 OAK ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4019
Practice Address - Country:US
Practice Address - Phone:503-585-4949
Practice Address - Fax:503-585-4965
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-14
Last Update Date:2021-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR104611175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist